NR 326 Week 1 EAQ Practice Questions

When conducting a client interview, which nurse's response is an example of back channeling?

"All right, go on... "

Which response will the nurse use to maintain the boundaries of a therapeutic relationship when a client asks, "Can we go out for coffee and a movie after I get discharged?"

"As your nurse, let's talk about how you can form social friendships.

Which question to help reduce anxiety would the nurse ask a client who is pacing the floor and appears extremely anxious?

"Shall we walk together for a while?"

Which approach would the nurse use for a client with major depression who refuses to participate in unit activities, claiming to be "just too tired"?

Accepting the client's feelings about activities while calmly setting firm limits Rationale Fatigue and apathy are symptoms of depression and should be accepted

Which legal complication might the nurse face for using a restraint without a legal warrant on a client?

False imprisonment

Which action would the nurse use to establish a therapeutic relationship with a withdrawn, reclusive client?

Help the client keep anxiety to a minimum.

During the working phase of a therapeutic relationship, the client suddenly becomes very hostile after several difficult sessions. Which interpretation would the nurse make?

Hostility is used as a defense because self-disclosure has raised anxiety.

Which behaviors would the nurse expect the client to do during the working phase of a therapeutic relationship according to Peplau's model of the nurse-client relationship? Select all that apply

Initiate topics of discussion. Accept limits on unacceptable behavior. Express emotions related to transference.

Which action indicates that the nurse is actively listening to the client?

Interpreting what the client is saying and restating it for clarification

Which approach would the nurse use when working with clients who use manipulative, acting-out behaviors?

Sincere, cautious, and consistent

Which response would the nurse make to a client diagnosed with acute depression who says, "God is punishing me for my past sins"?

"You sound very upset about this." Rationale The nurse would say, "You sound very upset about this. "This response focuses on the client's feelings rather than the statement, and it serves to open channels of communication

An older client is able to perform activities of daily living, but has vague physical complaints and has experienced multiple deaths of friends and family and has lost their social roles. Which question is the most therapeutic?

"How do you feel about your life now?"

Which response would the nurse make to a manipulative client who shouts, "You've worked it so I can't go for a walk with the group today. You're as cunning as a fox. I hate you!"?

"I don't like hearing this kind of talk, but tell me more about your feelings.

During an admission interview, a client is expansive and distractible and demonstrates a fragmented, pressured, nonsequential pattern of speech. Which communication technique would the nurse use?

Closed questions Rational The nurse must use highly structured closed questions to help the client focus on a single topic.

Which legal ramification would be indicated when a newly admitted male client diagnosed with bipolar disorder who has a history of hyperactivity and combativeness is found later in the evening beating another client?

Because it was known that the client was frequently combative, close observation by the nursing staff was indicated.

Which statement would be appropriate to include in a lecture for nursing students related to ethics and legal principles?

Beneficence emphasizes promoting good, actively seeking benefit, and ensuring the client's well-being. Rationale Beneficence is the ethical principle that emphasizes promoting good, actively seeking benefit, and ensuring the client's well-being.

Which assessment item needs to be documented on a client with restraints? Select all that apply

Pulse near the restrained area Temperature of the restrained area Skin integrity surrounding the restraint Behavior leading to the need for restraint

Which strategy would the nurse use to help a depressed, withdrawn client who exhibits sadness through nonverbal behavior?

Cope with painful feelings by sharing them. Rationale Sharing painful feelings reduces the isolation and sense of uniqueness that these feelings can cause; sharing of these feelings usually decreases depression.

Which therapeutic technique can the nurse use when an anxious client exhibits pressured and rambling speech?

Focusing Rationale Focusing is used when a client rambles or jumps from topic to topic; the intended meaning is easier to understand if the client focuses on one specific aspect.

Which intervention related to restraint use is appropriate to delegate to unlicensed assistive personnel (UAP)?

Routine checks of the client while in restraints

Which approach would the nurse take for a tearful, silent client who is admitted to the mental health unit after attempting suicide?

Saying, "I see that you're crying. Tell me what's going on in your life, and we can work on helping you."

The nurse says, "Let's see whether we both mean the same thing. " Which communication technique is the nurse using?

Seeking consensual validation Rationale Seeking consensual validation is a technique that prevents misunderstanding so the client and the nurse can work toward a common goal in the therapeutic relationship.

Which element is the basic therapeutic tool that the nurse uses to foster a client's ability to cope?

Self Rationale By offering self, the nurse is being present, attentive, and actively listening.

Which intervention would the nurse implement for a disturbed, acting-out client in the fetal position?

Sitting down beside the client and saying, "I'm here to spend time with you." Rationale The nurse would sit down beside the client and say, "I'm here to spend time with you." This shows acceptance of the client at the current level and allows the client to set the pace of the relationship.

Which intervention would the nurse include in a plan of care for a client with an anxiety disorder?

Supporting the verbalization of feelings by the client

Which nursing action best prepares a client for termination of the therapeutic relationship?

Telling the client during the first meeting how long the therapeutic relationship will last

Which approach would the nurse take for a client with hallucinations who suddenly rises and shouts, "Stop saying that. Who do you think you are"?

Telling the client that the voices are not heard by the nurse, then offering to listen to music together

Which legal aspect would be indicated when a nurse informs the nosy, hyperactive client, "Unless you're quiet, you'll be isolated and put in restraints, if necessary"?

The information given to the client is actually considered assault. Rational A threat is considered a type of assault (legally, an intentional tort).

Which legal implication would the nurse understand about applying restraints to a client?

The nurse can be charged with assault and battery for using restraints improperly.

Which action during the admission assessment would the nurse take for an involuntary admitted client who says, "I am the second son of God & need to say a prayer"?

Wait until the client finishes the prayer and then complete the assessment.

The nurse is caring for a client who is displaying increased agitation and anger that is not responding to de-escalatory techniques. Which interventions would the nurse perform next to maintain client and staff safety? Select all that apply.

Apply restraints. Place in seclusion. Administer medication.

Which action would the nurse use for a client who is rushing down the hall of the mental health unit, rapidly tapping their fingers against the wall?

Approach the client in a nonthreatening manner to determine the cause of the agitation.

Which intervention is most important for maintaining the safety of a restrained client?

Assess every 15 minutes.

A client who has a history of a short temper and physically abusive behavior is extremely anxious at the time of admission. Which nursing action is the priority?

Assign a staff member to supervise the client in the admission area.

A client calls out to all nursing staff members who pass by the door and asks them to get something. How can the nurse best manage this problem while meeting this client's needs?

Assign one staff member to approach the client regularly and interact with the client.

Which purpose is served by establishing a therapeutic nurse-client relationship?

Assisting the client in acquiring more effective behavior

Place these crisis interventions in the order the nurse would implement them for a client experiencing escalating levels of anxiety.

Attempt to identify the source of the anxiety. Encourage deep breathing and relaxation techniques. Provide firm but kind directions. Place the client in restraints if deemed dangerous.

Which action would the nurse take for a client who paces back and forth across the floor, speaks incoherently, and continually talks to and verbally fights with people who are not present?

Provide emotional support while demonstrating acceptance of the client.

Which quality is the most important tool the nurse brings to the therapeutic nurse-client relationship?

The self and a desire to help

The nurse is providing restraint education to a group of nursing students. Which reason to use restraints is incorrect to teach?

To prevent an adult client from getting up at night when there is insufficient staffing on the unit

Which action is the priority when the nurse is establishing a therapeutic environment for a client?

Ensuring the client's safety Rationale Safety is the priority before any other intervention is provided.

Which response will the nurse use when a newly admitted client looks at but does not verbally speak to the nurse

"I'd like to offer help and tell you about the services available on the mental health unit."

Which statement demonstrates that a psychiatric nurse has successfully fostered a therapeutic nurse-client relationship?

"My clients and I are partners in the planning that helps meet their physical and mental health needs."

Which response would the nurse make to a client who says, "I suppose you're going to ask me about my suicide attempt"?

"Tell me how you feel about it.

Which initial question by the nurse would be most therapeutic to alleviate the anxiety of the client who is pacing the floor and appears extremely anxious?

"Where would you like to walk with me?"

Which nursing responsibility is specific to caring for a client who is placed in seclusion?

Documenting the client's behavior and the events leading up to the seclusion Rationale Seclusion and restraints are special procedures for dealing with aggressive behavior for the protection of the client and others; clear documentation is essential when the client's rights are restricted.

Which undertaking would the nurse suggest for an emotionally disturbed client who is ready to begin participating in therapeutic social activities?

Drawing pictures with the nurse

Which legal principle is applied when the nurse fails to act in a reasonable, prudent manner?

Malpractice

During a therapy session of a bonded and well-established group, a client begins to cry and says, "My husband wants a divorce. " Which response would the nurse use?

Observe how the group responds to her statement. Rationale When a group is bonded, the members become the therapeutic resource; so the nurse would not immediately intervene because the client made the statement to the group.

The nurse places a client in restraints due to violent combative behavior. Which intervention would the nurse perform next?

Obtain a written or verbal prescription. Rational The nurse can use restraint or seclusion when client behavior is violent, and it is an emergency. However, the next nursing intervention should be to obtain a verbal or written prescription for their use.